Testicular Torsion

What is Testicular Torsion?

Torsion of the testis is a pathological twisting of the spermatic cord, which is caused by turning the fold between the testicle and its appendage (mesorchium). And this, in turn, is the cause of infringement or necrosis of testicular tissue.

The frequency of detection of testicular torsion in urological clinics is 1 in 500 patients. 20% of cases of the disease are detected in the first 10 years of a boy’s life. At the age of 10 years before puberty is diagnosed in 50% of patients. As can be seen, mechanical factors, for example, testicular torsion, play the main role in the etiopathoginesis of acute diseases of the testes of children.

Testicular Torsion Classification
There are two forms of the disease:

  1. Non-vaginal testicular torsion – above the parietal attachment of the leaf of the vaginal process of the peritoneum. It is diagnosed before the age of 1 year.
  2. Intravaginal testicular torsion. The disease often affects children than adults.

Causes Torsion

Important factors that trigger testicular torsion can be bruises and scrotal injuries, abdominal tension, sudden movements, followed by a reflex contraction of the muscle that lifts the testicle. If there is no normal attachment of the testicle to the bottom of the scrotum (an anomaly that occurs during the period when the appendage joins the testicle), mutual fixation is violated. This, in turn, leads to the separation of these entities. It is subject to twisting of testicles in case of malformations caused by cryptorchidism (impaired migration to the scrotum).

Pathogenesis during Testicular Torsion

The rotation of the testicle around the vertical axis is noted. If the rotation of the testicle and spermatic cord is greater than 180 °, there is a circulatory disturbance, and multiple hemorrhages are observed in the testicle, vein thrombosis of the spermatic cord is diagnosed, serous-hemorrhagic transudate appears in the cavity of the testicle membrane. The scrotal skin also becomes swollen.

Non-vaginal (suprashell) torsion of the testicle occurs along with its membranes. Regarding the vaginal process of the peritoneum, the testicles are located mesoperitoneally, and its fixation is not broken. The main importance for the development of this pathology is not a malformation of it, but the morphological immaturity of the spermatic cord and the tissues surrounding it. This is the hypertonicity of the muscle that raises the testicle, loose fusion of the membranes, a wide short inguinal canal, which is almost directly directed.

Intravaginal (intrathecal) testicular torsion – an intravaginal form – is noted in the vaginal cavity. The disease is diagnosed in children after 3 years, especially at the age of 10 to 16 years. Torsion of the testicle in this case occurs in this way. During the contraction of the muscle that raises the testicle, it, like the surrounding shells, is pulled upward, making a rotational movement. The sweat and rigidity of the fusion of the membranes, together with the inguinal canal, which intimately covers the spermatic cord in the form of a tube (in older children), does not allow the testicle to completely wrap around its axis. This leads to the fact that at a certain moment the rotation stops.

A testicle with a long mesentery and, as a result, having a high degree of mobility inside the cavity of the vaginal process of the peritoneum, continues to rotate by inertia. Muscle fibers relax later. The testicle, raised in the upper part of the scrotum cavity, is fixed in a horizontal position, since the convex parts hold it.

In the future, with the contraction of the muscle that raises the testicle, the inversion continues. The longer the mesentery is, the contraction force of the muscle raising the testicles is greater, and the mass of the testicle is higher, the more pronounced is the inversion. The increase in the number of cases of intranaginal twisting in the prepubertal and puberty periods is explained by a disproportionate increase in the mass of the testicle at this age. This is evidence that in the mechanism of intravaginal testicular torsion, an imbalance in the growth of the reproductive apparatus is important, which does not exclude the influence of other factors.

Symptoms Torsion of the Testicle

Symptoms of testicular torsion are acute. The disease manifests itself in sharp pains in the testicle (in the corresponding half of the scrotum), which radiate to the inguinal region. Nausea, vomiting, and a collapoid state are sometimes possible.

Symptoms of testicular torsion depend on the age of the child and on that. How long he got sick. In newborns, pathology is most often diagnosed during an initial physical examination in the form of a painless increase in half of the scrotum. Often, redness or pale skin of the scrotum and hydrocele is found. Infants are restless, often screaming and giving up on their breasts. Older people complain of symptoms such as pain in the groin and lower abdomen. In the area of ​​the external inguinal ring or in the upper third of the scrotum, a tumor-like painful formation is noted. Later, the twisted testicle is more elevated, and in case of an attempt to raise it higher, the pain is significantly increased (Prehn symptom).

Testicular Torsion Complications
The issues of prevention, timely diagnosis and treatment of acute diseases of the scrotum are of great importance. The reasons for this are:

  1. 77-87.3% of patients are able-bodied men aged 20 to 40 years.
  2. In 40-80% of boys and men who had acute diseases of the scrotum, atrophy of spermatogenic epithelium is manifested. The result of this is infertility. If conservative treatment is chosen, testicular atrophy is possible. Later, surgical treatment leads either to the removal of the appendage or testicle, or to its atrophy.

Atrophy of the testicles after transferred orthoepididymitis

  1. Progression of ischemic necrosis.
  2. The pathology of the hematotesticular barrier and the development of autoimmune aggression.
  3. The damaging effect of the etiological factor directly on the parenchyma.

During clinical and morphological studies, it was proved that for all forms of acute diseases of the scrotum, very similar, often identical, processes are characteristic. They are manifested by neurodystrophic tissue changes and a characteristic clinical picture.

Acute diseases of the scrotum cause, most often, identical changes in spermatogenesis, which are expressed in pathospermia, in a decrease in DNA in spermatozoa, in a decrease in the area of ​​the nucleus and head of spermatozoa, in violation of the content of trace elements of ejaculate. In this case, ischemic necrosis becomes a consequence of edema of the parenchyma, in particular, its protein coat. All these factors justify the recent trend of early surgical treatment of acute diseases of the scrotum. This form of treatment makes it possible to quickly eliminate ischemia, to diagnose the disease at the right time. And this allows you to save the functional ability of the testicle.

Early surgical intervention is necessary for the development of reactive dropsy of the testicle, severe pain, twisting of the testicle hydatida and its appendage, purulent inflammation and suspected rupture of the scrotum.

Diagnosis of Testicular Torsion

It is necessary to carefully collect all the information about the patient’s illness. The following factors should be noted: how long ago the scrotum was injured, hematuria, dysuria, sexual activity, discharge from the urethra, the time from the onset of clinical manifestations. It is important to examine the genitals, abdominal cavity, and perform rectal examinations. It is important to pay special attention to the absence or presence of secretions from the urethra, the color of the scrotum, and the position of the affected testicle, its axis; find out if there is a hydrocele on the opposite side, whether there is an induction or excess tissue in the testicle or its appendage.

The testicle is most often palpated at the upper edge of the scrotum. This is because the seed is shortened. During palpation, the scrotum is practically not painful. Sometimes during torsion, the appendage may be located in front of the testicle. As a result of torsion, the spermatic cord is thickened. In the future, swelling and hyperemia of the scrotum are visible. Since lymph outflow is impaired, a secondary hydrocele appears. To exclude infection, it is important to conduct a urinalysis. On Doppler ultrasound, the architectonics of the testicle and its appendage are clearly visible. According to the test results, a qualified doctor can determine the absence or presence of blood flow in the testicle.

Echography of testicular torsion is characterized by the inhomogeneity of the image of the parenchyma and the random alternation of hypo- and hyperechoic regions, thickening of the integumentary tissues of the scrotum, edematous hyperechoic appendage, and a small volume of hydrocele. At an early stage, echographically during scanning in the gray scale mode, it is possible not to detect changes. In addition, they may be nonspecific (changes in echo density). Later, a change in structure is determined (bleeding, heart attack).

During comparative studies, it was proved that during the operation, testicles with unchanged echo density are viable. While testicles heterogeneous in echogenicity or hypoechoic are not viable. Other echographic signs (such as the presence of reactive hydrocele, size, blood supply and skin thickness of the scrotum) are insignificant prognostically. It is necessary to apply tissue (energy) Doppler mapping. It is important to conduct the study symmetrically. This allows you to detect the smallest changes, such as with spontaneous resolution or incomplete torsion. In the affected organ, blood flow is impoverished. It may even not be fully determined (in case of inflammation, the blood flow increases). Spontaneous elimination of torsion causes a reactive increase in blood flow, clearly visible in comparison with previous studies.

To determine the nature of the contents of the membranes (exudate, blood), a diagnostic puncture and diaphanoscopy are performed.

Differential diagnosis of testicular torsion
Differential diagnosis of testicular torsion is performed with inflammation of the testicle (orchitis), which complicates infectious mumps, and with allergic Quincke edema. With the latter, the entire scrotum is usually enlarged. All its layers are saturated with liquid, a water bubble forms under the thinned skin.

Testicular Torsion Treatment

Non-drug treatment of testicular torsion
In the first hours of the disease, if external manual detorsion is performed, torsion can be eliminated in 2-3% of patients.

Outdoor Manual Testors Detorsion
The patient is placed on his back. Detorsion is performed in the opposite direction of the testicle inversion. In this case, it is important to remember that the left testicle rotates counterclockwise, and the right one clockwise. Choosing the direction of untwisting the testicle, it is convenient to use the middle seam of the scrotum as a guideline. An egg with tissues of the scrotum is captured and rotated 180 ° in the opposite direction to the median suture of the skin of the scrotum. At the same time carry out a light traction of the testicle down. Then it is lowered. This manipulation is repeated several times. In the case of successful detorsion, the pain in the testicle, which occupies its usual position in the scrotum, completely disappears or decreases. If conservative detorsion is ineffective, after 1-2 minutes, the manipulation is stopped. And the patient is prescribed surgical treatment. The older the child and the earlier detorsion, the higher the effectiveness of the operation.

Surgical treatment of testicular torsion
If it is impossible to perform an ultrasound or the results of the study are uncertain, the patient needs to undergo surgery.

When diagnosing edema scrotum syndrome, urgent surgery is needed. In this case, the increased sensitivity of the testicle to ischemia, it can die quickly, since after 6 hours irreversible changes occur.

The choice of access to the focus of pathology depends on the age of the child and the form of inversion. Inguinal access is used in newborns and infants, since they are most often diagnosed with an extravaginal form of torsion. In older children and adults, access via the scrotum is more convenient, since the intravaginal form predominates.

Operation technique for testicular torsion
In all cases of the disease, the testicle is exposed to the albumen. This allows a wide resection. Then determine the shape of the inversion. The testicle is dislocated into the wound, detorsion is performed, and the organ viability is assessed. In order to improve microcirculation and determine the preservation of the testicle, it is recommended that 10-20 ml of a 0.25-0.5% solution of procaine (novocaine) with sodium heparin be introduced into the spermatic cord. If blood circulation does not improve after 15 minutes, an orchiectomy is indicated to the patient. To improve blood circulation, heat compresses with isotonic sodium chloride solution can be applied for 20-30 minutes. If blood circulation is restored, the testicle will return to its normal color.

Only with complete necrosis can a testicle be removed. In the case when it is difficult to determine the degree of viability of the affected testicle, Ya.B. Yudin. A.F. Sakhovsky recommend the use of transillumination examination of the testis on the operating table. If the testicle is translucent, this indicates its viability. If this symptom is absent, the researchers recommend making an incision in the testicle at the lower pole. If bleeding occurs from the vessels of this membrane, this is evidence of organ viability. A necrotic testicle, despite all attempts to improve its vascularization, does not change color. Below the strangulation site, there is no vascular pulsation, and the vessels of the albumen do not bleed.

A preserved testicle with several sutures (usually 2-3) for the lower ligament of the appendage is sutured to the scrotal septum. In this case, there should be no tension of the elements of the spermatic cord. As with acute orchoepilidymitis, a drainage tube is inserted into the wound. Within 2-3 days, they provide constant irrigation with antibiotics (depending on the severity of the inflammatory process and destructive changes). In the case of testicular torsion with cryptorchidism after detorsion, the above manipulations are performed. The atrophied testicle is removed, and the viable is lowered into the scrotum and fixed.

Further management
After the operation, patients are prescribed physiotherapy, sensitizing agents, drugs that normalize microcirculation in the damaged organ. Daily novocaine blockade of the spermatic cord is carried out, heparin sodium, reopoliglukin, etc. are administered intramuscularly. To reduce the permeability of the blood barrier, after surgery, patients are prescribed 0.3 – 1.5 g per day of acetylsalicylic acid for 6-7 days.

If necessary, in the future, in practice, you can use prophylactically orchidexy from the opposite side. This will prevent testicular torsion in the future.

It is proved that if you save a dead testicle, in the long-term period of the disease, sperm antibodies appear in the patient’s body. Torsion of the testicle often extends to another testicle, and this, as a result, leads to infertility.

Prevention Testicular Torsion

Fixation of the spermatic cord is considered to be fixation of the testicle in the scrotum, timely treatment of cryptorchidism.